Provider Demographics
NPI:1033537170
Name:JOHNSON, DESERAE LEI (LMT)
Entity Type:Individual
Prefix:MRS
First Name:DESERAE
Middle Name:LEI
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 W BOISE ST
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-3137
Mailing Address - Country:US
Mailing Address - Phone:208-409-0422
Mailing Address - Fax:
Practice Address - Street 1:1654 W BOISE ST
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-3137
Practice Address - Country:US
Practice Address - Phone:208-409-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-05
Last Update Date:2014-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-1035174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist